Abstract
BackgroundAnticoagulation is the mainstay of treatment for pulmonary embolism. However, if bleeding unfortunately occurs, the risks and benefits of anticoagulation present a challenge. Management of one hemorrhagic complication, retroperitoneal hematoma, is rare, difficult, and controversial.Case presentationA 73-year-old white man presented with left lower extremity swelling and dyspnea. He was tachycardic, hypertensive, and demonstrated poor oxygen saturation of 81% on ambient air. A computed tomography angiogram revealed a saddle pulmonary embolus. Tissue plasminogen activator was administered and he was started on a heparin infusion. He was eventually transitioned to enoxaparin. On the day of discharge, however, he had sudden onset of right leg numbness and weakness below his hip. A computed tomography of his head was not concerning for stroke, and neurology was consulted. Neurology was concerned for spinal cord infarction versus hematoma and recommended magnetic resonance imaging of his thoracic and lumbar spine. The magnetic resonance imaging revealed a left psoas hematoma. A computed tomography scan of his pelvis also showed a right psoas and iliacus hematoma. He was transitioned to a low intensity heparin infusion. The following day his left leg exhibited similar symptoms. There was concern of progressive and irreversible nerve damage due to compression if the hematomas were not drained. Interventional radiology was consulted for drainage. The heparin infusion was paused, drainage was performed, and the heparin infusion was reinitiated 6 hours following the procedure by interventional radiology. His blood counts and neurologic examination stabilized and eventually improved. He was discharged home on a novel anticoagulant.ConclusionsManagement of a retroperitoneal hematoma can commence with recognition of the warning signs of bleeding and neurological impairment, and consulting the appropriate services in case the need for intervention arises. A conservative approach of volume resuscitation and blood transfusion can be used initially, with the need for pausing or reversing anticoagulation being assessed on an individual basis with expert consultation. If intervention becomes necessary, other interventional radiology-based modalities can be used to identify and stop the bleeding source, and interventional radiology-guided drainage can be performed to decrease the hematoma burden and relieve neurological symptoms.
Highlights
Anticoagulation is the mainstay of treatment for pulmonary embolism
Management of a retroperitoneal hematoma can commence with recognition of the warning signs of bleeding and neurological impairment, and consulting the appropriate services in case the need for intervention arises
A conservative approach of volume resuscitation and blood transfusion can be used initially, with the need for pausing or reversing anticoagulation being assessed on an individual basis with expert consultation
Summary
1) Patients with confirmed PE should be given parenteral anticoagulation, with the risk of major bleeding being less than 3%. There are several risk factors that predispose patients to bleeding. The need for continuing anticoagulation should be reassessed, and risks and benefits should be explained to the patient before proceeding with any plan of action. NH admitted the patient to the hospital and initiated his care. AW was the attending physician who managed the patient’s care while hospitalized. GC was the resident physician who managed the patient’s care while hospitalized and was a major contributor in writing the manuscript. All authors read and approved the final manuscript. Ethics approval and consent to participate No approval was sought as this was a retrospective case report and the patient was at no risk from this case report. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations
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